Altnaglevin Hospital, Londonderry - 22 November 2011

Reference
number
Recommendations
18 All staff have a responsibility to ensure that hand
hygiene is carried out in line with WHO guidelines and
that all PPE is used appropriately
Designated
department
Support
Services
Nursing
Action required
held laminated cards which states the correct
dilution rates as an aid to correct practice.
Staff knowledge and processes will be
checked monthly on the introduction of the
new revised audit tool.
Support Services staff induction training/
BICS training programme incorporates hand
hygiene and PPE requirements.
Hand hygiene is taught at induction and
mandatory training and the practice of
Nursing and Medical staff is monitored every
2 weeks by their peers, exceptions are
reported through robust accountability
systems.
Date for
completion/
timescale
Commenced
and on-going
19 Systems and processes should be in place to assure
that staff knowledge and practice is kept up to date
regarding isolation, cleaning and decontamination of
equipment
Support
Services
Nursing
Hand hygiene scores are reviewed at the
monthly accountability meeting and nursing
matters are dealt with at that meeting with
corrective action taken in terms of repeat
hand hygiene until 5 consecutive days
scoring 95% is achieved.
Staff are advised that where a member of the
medical staff fail the hand hygiene this is to
escalated to the clinical lead for that area
The medical director is to be advised on the
occasion that an individual doctor fails three
times.
Support Services BICS training programme
incorporate cleaning procedures for isolation
and decontamination of equipment.
Attendance at IPC induction and mandatory
training on a 2 yearly basis is mandatory for
all clinical staff in the Trust.
Ad hoc audits of practice related to
commodes and other high risk equipment do
Commenced
and on-going
39